Flashcards in Constipation, Diarrhea, and GERD Deck (145):
What are the Rome III criteria for functional constipation?
at least two of the following for the last 3 months with onset in the prior 6 months: straining (25% of BMs), lumpy or hard stool (Bristol Stool Scale Form 1 or 2 - 25% of BMs), sensation of incomplete evacuation (25% of BMs), manual maneuvers (25% of BMs), sensation of obstruction (25% of BMs), < 3 BMs/week; loose stools rarely present without laxatives; insufficient criteria for IBS
What is stercoral ulceration?
ulcer of the colon due to pressure and irritation resulting from severe, prolonged constipation due to large bowel obstruction (commonly located in the rectum)
What is the puborectalis muscle?
muscle that contributes towards the maintenance of fecal continence - loops around the rectum like a sling, pulling the rectum forward to create a more acute angle between the rectum and the anal canal => squatting fully relaxes the muscle and allows for easier defecation
What are the three types of primary colorectal dysfunction?
(1) slow transit constipation - delay throughout the colon (dysfunction of colonic smooth muscle or neuronal innervation and obstruction); (2) dyssynergic defecation - difficulty expelling stool from the anorectum; (3) IBS predominant constipation (abdominal pain and altered bowel habits)
What are common causes of secondary constipation?
endocrine/metabolic disorders, neurologic disorders, myogenic disorders, medications (opioids), psychiatric disorders (anorexia nervosa), chronic idiopathic constipation (no physiological abnormality)
What are some neurogenic disorders associated with chronic constipation?
DM, Hirschsprung disease (absence of ganglion cells), Chagas disease (disease of the nervous system that can cause megacolon and chronic constipation), MS, spinal cord injury
What are some non-neurogenic disorders associated with chronic constipation?
hypothyroidism, hypokalemia, anorexia nervosa, pregnancy
Which receptor is associated with opioid-induced chronic constipation?
mu-opioid receptors in the GI tract - opioids bind to these receptors, leading to inhibition of the propulsive activity of the intestine and slowing intestinal transit
Which drugs are commonly associated with constipation?
opiates, antihypertensives, CCBs, iron supplements, aluminum, analgesics, antihistamines, antispasmodics, antidepressants, antipsychotics, serotonin (5-HT3) receptor antagonists (block the vomiting reflex - ondansetron)
What are red flags associated with constipation?
hematochezia (passage of fresh blood through the anus), + fecal occult blood test, obstructive symptoms, acute onset constipation, severe constipation unresponsive to Tx, weight loss > 10 pounds, change in stool caliber, family Hx of colon cancer/IBD
What other factors can contribute to constipation?
immobility, chronic medical problems (pain, DM), psychosocial problems (isolation, poor nutrition)
How should you conduct an exam for constipation?
thorough Hx, rectal exam, and bowel diary => reserve other diagnostic studies for selected individuals
What are the treatments for constipation?
(1) lifestyle and dietary modification, (2) bulk laxatives (psyllium [Metamucil], polycarbophil [FiberCon], wheat dextriumn [Benefiber], methylcellulose [Citrucel]), (3) osmotic laxatives - contain polyethylene glycol (GoLYTELY, GlycoLax, and MiraLax), (4) colon secretagogues (lubiprostone), (5) enemas (only to prevent fecal impaction in PTs with several days of constipation)
What is the mechanism of action of osmotic laxatives (polyethylene glycol - GoLYTELY [electrolyte] and MiraLAX [powdered])?
hold water in the stool to soften the stool and increase the number of bowel movements - improves stool frequency and consistency => start with 17 g powder dissolved in 8 oz of water daily and titrate up/down to effect
What is the mechanism of action of bulk forming laxatives (psyllium seed/Metamucil, methylcellulose/Citrucel, calcium polycarbophil/FiberCon, wheat dextrin/Benefiber)?
natural or synthetic polysaccharides or cellulose derivatives - are not digested but absorb liquid in the intestines and swell to form a soft, bulky stool
What is pelvic floor dyssynergia/functional outlet disorder?
condition in which the external anal sphincter and the puborectalis muscle contract rather than relax during an attempted bowel movement - there is the sensation of incomplete emptying of the rectum; Dx made via manometry and balloon expulsion test => may be treated with biofeedback
What are the recommendations for establishing a regular pattern of bowel movement?
attempt to empty the bowel at the same time every day - within 2 hours of waking and within the first 30 minutes after a meal (to take advantage of postprandial increases in colonic motility); attempt a BM at least twice per day; strain no more than 5 minutes
What dietary changes are recommended to treat constipation?
increase fluid and fiber intake - fiber intake of 20-25 g/day
What are some types of natural laxatives that may be safe to use with constipation?
flaxseed, psyllium fiber, triphala (composed of 3 fruits common to the Indian subcontinent: Amalaki [Emblica officinalis], Bibhitaki [Terminalia belerica] and Haritaki [Terminalia chebula])
What is anorectal manometry?
a small, flexible sensor is placed in the rectum and connected to a computer with a recording device that measures the pressure and strength of the anal and rectal muscles - the patient is asked to perform certain maneuvers such as squeezing, relaxing, or pushing as if to pass stool - abnormal finding suggests a defecatory disorder
What is the balloon expulsion test?
PT is placed in a left lateral decubitus position with flexion of the knees and hips - a well lubricated empty balloon is gently inserted into the rectum and the balloon is inflated by a fixed volume (typically 50 mL of water or until the patients feel a desire to defecate) => PT is then asked to attempt to evacuate the balloon in the sitting position in privacy - abnormal finding suggests a defactory disorder
Which laboratory tests should be ordered in PTs with constipation?
complete metabolic panel (serum glucose, creatinine, calcium), CBC with differential, thyroid function tests
Which patients should receive laboratory testing with constipation?
PTs with hematochezia, weigh loss > 10 lbs., family Hx of colon cancer or IBD, anemia, positive fecal occult blood test
Which patients should receive diagnostic colonoscopy with constipation?
age < 50 years who have not previously had colon cancer screening, constipation with alarm features, prior to surgery for constipation
Which PTs should receive radiographic studies for constipation?
suspected megacolon and barium radiograph in PTs with suspected Hirschsprung disease
Which PTs should receive assessment with colon transit study for constipation?
those with infrequent defecation - used with radiopaque markers or wireless motility capsule
What is colonic transit time?
time it takes for stool to pass through the colon
What is defecography?
imaging study which provides information about anatomical and functional changes of the anorectum - most useful in examining anatomic causes of constipation - performed by placing 150 mL of barium into the PT's rectum and having PT squeeze, cough, or bear down
How is dyssynergia diagnosed on defecography?
presence of insufficient descent of the perineum (< 1 cm) and less than a normal change in the anorectal angle (< 15 degrees)
How is defecatory dysfunction managed?
suppositories (glycerin or biscodyl - liquify stool), biofeedback (used to correct inappropriate contraction of the pelvic floor muscles and external anal sphincter), or botulinum toxin injections into the puborectalis muscle (60-100 U into both sides of the muscle)
What is the recommended daily fiber intake?
25 to 30 g/day - there is a dose response between fiber intake, water intake, and fecal output (larger particle size fiber sources enhance fecal bulking) - PTs can add 2-6 Tbs of raw bran followed by a glass of water to achieve optimal fiber intake => side effects: bloating and gas
What is the mechanism of action of surfactants/softeners (docusate sodium/Colace)?
lower the surface tension of stool, allowing water to more easily enter - not as effective as other types of laxatives for chronic constipation
What is the mechanism of action of stimulant laxatives (bisacodyl/Dulcolax, senna/Senokot)?
alter electrolyte transport by the intestinal mucosa and increase intestinal motor activity
How is stool fecal impaction (solid immobile bulk of stool in the rectum) treated?
disimpacted with manual fragmentation or using flexible or rigid sigmoidoscopy with instrumentation - followed by enema with mineral oil to soften the stool and provide lubrication or daily warm water enemas for up to 3 days
What type of drug is linaclotide?
minimally absorbed peptide agonist of guanylate cyclase-C receptor that stimulates intestinal fluid secretion and transit - used to treat chronic idiopathic constipation (145 mcg/day)
What type of drug is lubiprostone?
locally acting chloride channel activator - enhances chloride-rich intestinal fluid secretion (24 mcg/day) - best used in patients who have no responded to other treatments
Which patients are candidates for subtotal colectomy with ileorectal anastomosis?
(1) chronic, severe, disabling symptoms unresponsive to medical therapy, (2) slow colonic transit, (3) *no* intestinal pseudoobstruction, (4) *no* pelvic floor dysfunction, (5) *no* abdominal pain as a prominent symptom - surgery is the treatment of choice of Hirschsprung disease
How is diarrhea defined?
passage of loose or watery stools at least 3X in 24 hours - reflects increased water content of stool due to impaired water absorption and/or active water secretion by the bowel
What is dysentery?
diarrhea with visible blood or mucus
What are the most common causes of acute infectious diarrhea?
viral infections (norovirus, rotavirus, adenovirus)
What are the most common causes of severe diarrhea?
bacteria (Salmonella, Campylobacter, Shigella, E coli, C diff)
When is an office evaluation warranted for acute diarrhea?
patients with persistent fever, bloody diarrhea, severe abdominal pain, symptoms of volume depletion, Hx of IBD
What are the common features of diarrhea of small bowel origin?
watery, large volume, and associated with abdominal cramping, bloating, and gas
What are the common features of diarrhea of large intestinal origin?
frequent, regular, small volume, painful BMs - fever, bloody/mucoid stools are common; RBCs and inflammatory cells routinely seen
What does timing of consumption of suspected contaminated food suggest about likely origins of diarrhea?
within 6 hours and with N/V - suggests ingestion of preformed toxin (Staph aureus or Bacillus cereus); 8 to 16 hours - C perfringens; > 16 hours - viral or bacterial infection
What are aspects of history important to capture when assessing diarrhea?
character of symptoms, duration, frequency, associated symptoms, food history (unpasteurized dairy products, raw/undercooked meat/fish, organic vitamins), exposure to animals, recent travel, occupation in day care centers, recent antibiotic use/medicines, past medical Hx (immunocompromised or nosocomial infection)
What should you look for in the physical exam of a PT with diarrhea?
signs of volume depletion (dry mucous membranes, diminished skin turgor, postural hypotension, altered sensorium), abdominal distension, pain with gentle percussion, abdominal rigidity, rebound tenderness
When should stool samples be taken in patients with acute community-acquired diarrhea?
severe illness (profuse watery diarrhea with hypovolemia, > 6 unformed stools in 24 hours, severe abdominal pain), signs/symptoms of inflammatory diarrhea (bloody diarrhea, small volume stools with blood/mucus, temp > 101.3 degrees), high-risk host features (age > 70, comorbidities, immunocompromised, IBD, pregnancy), symptoms persisting > one week, public health concerns
How should stool samples be taken in patients with suspected parasitic infections?
three specimens on consecutive days - ova and parasitic excretions may be intermittent and may give a false negative reading with only one sample
What are more uncommon causes of diarrhea that occur in immunocompromised PTs?
parasites, microsporidium (fungal infection), cytomegalovirus
What is a common cause of diarrhea in MSM?
proctitis - caused by STIs => perform anoscopy to identify anorectal discharge or rectal mucosal friability
What is the treatment for diarrhea?
#1 rehydration (PO - water, salt, and sugar) - diluted fruit juices or flavored soft drinks, (Gatorade not equivalent to rehydration solutions), saltine crackers and broths or soup for PTs with mild symptoms; oral rehydration solutions for PTs with moderate/severe symptoms
What is the recommended composition of oral rehydration solutions for treatment of diarrhea?
3.5 g NaCl, 2.9 g sodium bicarbonate, 1.5 g potassium chloride, 20 g glucose - similar solution can be made with 1/2 t salt, 1/2 t baking soda, and 4 Tbs sugar in 1 L of water
What are dietary recommendations during an episode of acute diarrhea?
boiled starches and cereals (potatoes, noodles, rice, wheat, oat) with salt, crackers, bananas - avoid foods with high fat content; dairy products (except yogurt) may be difficult to digest
When is empiric antibiotic therapy warranted in the treatment of diarrhea?
severe disease (fever, > 6 stools/day, volume depletion requiring hospitalization), bloody/mucoid stools (suggests bacterial infection), host factors (age > 70, immunocompromised, cardiac conditions), prolonged disease (> 1 week) that has not improved, public health concerns
What is the best choice of agent for empiric antibiotic therapy in treatment of diarrhea?
oral fluoroquinolone (ciprofloxacin 500 mg BID, levofloxacin 500 mg daily, or norfloxacin 400 mg BID) for 3-5 days - alternatives: azithromycin (500 mg PO daily for 3 days) or erythromycin (500 mg PO BID for 5 days)
Which causative agent of diarrhea should *not* be treated with antibiotics?
enterohemorrhagic E coli - can precipitate hemolytic-uremic syndrome
What can PTs with diarrhea take if they want symptomatic relief?
antimotility agent (loperamide/Imodium 4 mg or bismuth salicylate/Pepto-Bismol 30 mL) - use cautiously in patients with no or low-grade fever and lack of blood in stool and use fluids aggressively
What is the role for probiotics in treatment of diarrhea?
assist in maintaining or recolonizing the intestine with nonpathogenic flora - Lactobacillus GG (infectious diarrhea) or Saccharomyces boulardii (C diff)
What is dysphagia?
subjective sensation of difficulty or abnormality of swallowing - suggests the presence of an organic abnormality in the passage of solids or liquids from the oral cavity to the stomach - includes sensation of inability to initiate a swallow to sensation of substances being hindered in their passage through the esophagus
What is odynophagia?
pain with swallowing
What is globus sensation?
persistent or intermittent nonpainful sensation of a lump or foreign body in the throat with the occurrence of the sensation between meals and in the absence of dysphagia or odynophagia - ongoing for last 3 months with symptom onset at least 6 months prior
What are the different categories of dysphagia?
(1) oropharyngeal - difficulty initiating a swallow (point to cervical region to indicate site of symptoms, associated with coughing, choking, nasal regurgitation) and (2) esophageal - difficulty swallowing several seconds after initiating a swallow and sensation of food getting stuck in the esophagus
What is the likely cause of dysphagia to both solids and liquids?
What is the likely cause of dysphagia to solids that progresses to involve liquids?
What are the diagnostic tests used to diagnose dysphagia?
barium swallow (esophageal lesion or stricture), upper endoscopy (esophageal), motility testing (manometry - measures the rhythmic muscle contractions that occur in your esophagus when you swallow)
What are the differential diagnoses for esophageal dysphagia?
food impaction (most common), peptic stricture (complication of acid reflux), esophageal spasm (corkscrew-like appearance on imaging), eosinophilic esophagitis, esophageal webs (thin mucosal fold that protrudes into the lumen)/rings (mucosal strictures), carcinoma, radiation injury, achalasia (loss of peristalsis in distal esophagus), systemic sclerosis, Sjogren's syndrome
What is achalasia?
loss of peristalsis in distal esophagus and failure of lower esophageal sphincter relaxation while swallowing
What are signs and symptoms of achalasia?
progressively worsening dysphagia for solids and liquids and regurgitation of bland undigested food or saliva, chest pain, heartburn, difficulty belching, dilated esophagus that terminates in beak-like narrowing, aperistalsis, poor emptying of barium from esophagus - manometry required to establish the diagnosis
What is functional dysphagia?
sense of solid and/or liquid lodging or passing abnormally through esophagus, absence of mucosal/structural abnormality, absence of GERD or other motor disorder - ongoing for 3 months with onset at least 6 months prior
What is the etiology of a patient with esophageal dysphagia to solids and/or liquids that is intermittent?
primary or secondary esophageal motor disorder
What are the possible etiologies of a patient with esophageal dysphagia to solids and/or liquids that is progressive?
scleroderma (with chronic heartburn) or achalasia (with regurgitation, respiratory symptoms, weight loss)
What is the etiology of a patient with esophageal dysphagia to solids only (mechanical) that is nonprogressive?
esophageal (Schatzki) ring/web or eosinophilic esophagitis
What are the possible etiologies of a patient with esophageal dysphagia to solids only (mechanical) that is progressive?
peptic ulcer (chronic heartburn) or esophageal cancer (elderly, significant weight loss, anemia)
What is gastroesophageal reflux disease?
reflux of stomach contents causes troublesome symptoms and/or complications - patients do not necessarily have esophageal inflammation
What is reflux esophagitis?
type of GERD with endoscopic or histopathologic evidence of esophageal inflammation
What are the most common symptoms of GERD?
heartburn (pyrosis) - burning sensation in the retrosternal area in the postprandial period, regurgitation - perception of flow of reflexed gastric content into the mouth or hypopharynx, dysphagia, bronchospasm, laryngitis, chronic cough
What are other frequent symptoms of GERD?
chest pain (may mimic angina - resolves with antacids), water brash/hypersalivation, globus sensation (feeling of lump in the throat), odynophagia (usually indicates esophageal ulcer), nausea
What are the common histological findings in PTs with GERD?
dilation of the intercellular spaces, thickening of the basal cell layer, elongation of the papillae of the epithelium
How is GERD diagnosed?
based on clinical symptoms alone - patients presenting with any of the typical clinical manifestations can be presumed to have GERD (response to antisecretory therapy is not a diagnostic criterion)
What is the Los Angeles classification of esophagitis?
grades esophagitis severity by the extent of mucosal abnormality - mucosal break refers to an area of slough adjacent to more normal mucosa
What are the grading categories in the Los Angeles classification system for esophagitis?
A - one or more mucosal breaks < 5 mm; B - at least one mucosal break > 5 mm but not continuous between the tops of adjacent mucosal folds; C - at least one mucosal break continuous between the tops of adjacent mucosal folds but which is not circumferential; D - mucosal break that involves at least 3/4 of the luminal circuference
When is ambulatory pH monitoring used in diagnosing GERD?
to confirm disease in PTs with persistent symptoms who do not have evidence of mucosal damage on endoscopy - tests are traditionally conducted for 24 hours with patients advised to consume an unrestricted diet => % of time with intraesophageal pH below 4 is used to discriminate physiologic and pathologic esophageal reflux
When is esophageal manometry used in the diagnosis of GERD?
in PTs with symptoms and normal upper endoscopy - used to identify alternative diagnoses (e.g., achalasia) and ensure that ambulatory pH probes are placed correctly
What is gastroesophageal reflux?
normal passage of gastric contents into the esophagus - becomes a disease (GERD) when it causes macroscopic damage to the esophagus or causes symptoms that reduce QOL
What are the two categories of GERD?
(1) erosive esophagitis - endoscopically visible breaks in the distal esophageal mucosa and (2) nonerosive reflux disease or endoscopy negative reflux disease - presence of troublesome symptoms without visible esophageal mucosal injury
When is upper endoscopy recommended in GERD?
(1) PTs with heartburn and alarm symptoms (dysphagia, odynophagia, GI bleeding, anemia, weight loss, recurrent vomiting), (2) PTs with esophagitis graded as Los Angeles criteria C or D, (3) to screen for Barrett's esophagus, (4) PTs with GERD that persists despite Tx of 4-8 weeks of BID PPI
What is the recommended approach to Tx of GERD?
step-up: incrementally increase potency of therapy until symptom control achieved - preferred for PTs with mild and intermittent symptoms who have no evidence of erosive esophagitis on upper endoscopy
What is the course of step-up therapy in GERD?
(1) lifestyle/dietary modification, (2) antacids - relieve heartburn in 5 minutes but only 30-60 minutes duration of effect, (3) histamine 2 receptor antagonists, (4) PPIs
What are the recommended lifestyle modifications in GERD?
weight loss, elevating head of bed, refraining from assuming supine position after meals, avoidance of meals 2-3 hours before bedtime, avoidance of triggers, avoid tight-fitting clothes, promote salivation (lozenges), avoid tobacco/alcohol, abdominal breathing exercises, eating smaller meals, avoiding high fat content foods
What are common food-related triggers with GERD?
fatty foods, caffeine, chocolate, spicy foods, carbonated beverages, peppermint
What is the mechanism of action of H2 blockers (famotidine [Pepcid 10-20 mg BID], cimetidine [Tagamet 200-400 mg BID], ranitidine [Zantac 75-150 mg BID])?
decrease secretion of acid by inhibiting the histamine 2 receptor on the gastric parietal cells (onset of action is 2.5 hours but last 4-10 hours)
What is the mechanism of action of PPIs (omeprazole 20-40 mg, pantoprazole (Protonix 20-40 mg), esomeprazole 20-40 mg, lansoprazole 15-30 mg, rabeprazole 10-20 mg)?
inhibit gastric secretion by irreversibly binding to and inhibiting the hydrogen-potassium ATPase pump - should be taken 30 minutes before first meal of day and taken daily for at least 5 days
When is step down (i.e., begin Tx with PPI and taper to lower levels of medications) therapy recommended in GERD?
PTs with erosive esophagitis, frequent (2+ episodes/week) and/or severe symptoms
How is refractory GERD defined?
PTs who fail to respond to 8 weeks of once-daily PPI therapy - use twice-daily to improve symptoms relief
What is the recommended Tx of GERD in pregnancy?
(1) lifestyle/dietary change, (2) antacids (avoid those with sodium bicarbonate and magnesium trisilicate), (3) sucralfate (1 g PO TID), (4) H2 blockers (ranitidine 75-150 mg BID or cimetidine 200-400 mg BID), (5) PPIs (omeprazole 20-40 mg or pantoprazole 20-40 mg), (6) upper endoscopy (only with strong indication and postponed until 2nd trimester)
When is upper endoscopy indicated for PTs with recurrent symptoms of GERD?
if symptoms recur within 3 months - if symptoms recur 3 or more months following discontinuation of acid suppression, restart last effective acid suppressive therapy
What is the first line therapy for PTs with newly diagnosed GERD?
avoidance of trigger foods
A PT has eosphageal columnar epithelial metaplasia, what is he at risk for?
What is the role of PPIs in treatment of GERD?
increase the pH of the stomach
What diagnostic testing is recommended in a patient with signs and symptoms of GERD?
none - the diagnosis is clinical and does not require use of trial therapy to confirm
What is likely to be found in a 50 year old woman with new onset reflux esophagitis?
recent initiation of estrogen-progestin hormonal therapy
What is a common manifestation in patients with persistent GERD?
chronic cough and sore throat
Which anti-hypertensive medication can cause symptoms of heartburn in GERD to get worse?
When precribing fluoroquinolone antibiotics in PTs with GERD, what is the recommendation for taking with other medications?
separate other drugs (e.g., antacids) by 2 to 4 hour before or 4 to 6 hours after taking the antibiotic
What is the next step in treatment for a patient who has been on therapeutic dosages of PPI for 6 months without improvement?
evaluation with upper GI endoscopy
What are common risk factors for Barrett esophagus?
Hx of cigarette smoking, age > 50 years, male gender, White/Latino ethnicity
What is the usual method of evaluation for Barrett esophagus?
upper GI endoscopy with biopsy
In a PT with Barrett esophagus who has shown no signs of dysplasia in 2 consecutive evaluations within the past year, what is the recommendation for future surveillance testing?
every 3 years
What is the most common form of esophageal cancer in the U.S.?
Where is esophageal adenocarcinoma usually located?
at the junction of the esophagus and stomach
Where is esophageal squamous cell cancer usually located?
in the upper esophagus
What are the most common symptoms of GERD?
dyspepsia, chest pain at rest, postprandial fullness
What are common non-GI symptoms of GERD?
chronic hoarseness, sore throat, nocturnal cough, wheezing
What is GERD?
gastroesophageal reflux that is associated with esophageal tissue damage - due to decreased lower esophageal sphincter tone and the resulting reflux of gastric contents
Which drugs are associated with decrease in lower esophageal sphincter pressure?
estrogen, progesterone/progestins, theophylline, calcium channel blockers, nicotine
What are some alarm symptoms in GERD?
dysphagia, odynophagia, GI bleeding, unexplained weight loss, persistent chest pain, iron-deficiency anemia - send PT for upper endoscopy
What should be the next phase of evaluation in PTs with chronic constipation and a normal imaging study?
colonic transit and pelvic floor dysfunction
In older adults, constipation may be associated with what?
fecal impaction and fecal incontinence
What are some adverse effects of fecal impaction?
stercoral ulceration, bleeding, anemia
What are the causes of constipation in IBS-constipation predominant?
slow colonic transit, dyssynergia, visceral hypersensitivity
What is constipation?
disordered movement of stool through the colon or anorectum (movement of matter through the proximal GI tract is generally normal)
What is the best way to determine a PT's "normal" bowel pattern?
through a 2 week bowel diary and reassurance that there is no such thing as "normal" (i.e., there is tremendous variation across individuals)
What is the process for normal defecation?
relaxation of the puborectalis and external anal sphincter muscles, increased intraabdominal pressure, inhibition of segmental colonic activity
What are the possible pathophysiological problems in PTs with colonic dyssynergia?
inability to contract the abdominal muscles, inability to relax anal sphincter, contraction of anal sphincter, absence of perineal descent
What tests should be ordered in PTs with red flags for constipation?
CBC, serum glucose, creatinine, calcium, TSH, radiography, endoscopy
In PTs with constipation, when are plain films appropriate?
to detect significant fecal retention and megacolon
What is required for a diagnosis of dyssynergic defecation?
at least two positive results of the following studies: anorectal manometry, anal sphincter electromanometry, defecography, impaired balloon expulsion
What is the first line treatment for slow colonic transit?
What is the first line treatment for defecating disorders?
biofeedback, pelvic floor retraining
What are common metabolic causes of constipation?
DM, hypothyroidism, hypercalcemia, heavy metal intoxication
What is colonic inertia?
delayed passage of radiopaque markers through the proximal colon in the absence of defecation abnormality - most common cause of severe constipation
What is megacolon?
increased rectal compliance and elasticity - blunts the rectal sensation to evacuate
Why do nervous system diseases result in constipation?
colonic and anorectal function are coordinated by enteric, sympathetic, and parasympathetic nerves
What are the different categories of diarrhea by length of time?
acute: < 14 days; persistent: 14 -30 days; chronic: > 30 days
What is the likely etiology if diarrhea progresses to systemic complaints (e.g., headaches and muscle aches - stiff neck in pregnant woman)?
typhoidal illness or Listeria monocytogenes
What etiology of diarrhea is associated with exposure to zoo animals/reptiles?
What are the common causes of diarrhea in day care settings?
Shigella, Cryptosporidium, Giardia - rotavirus largely eliminated due to vaccination
When is an office visit warranted with diarrhea?
persistent fever, bloody diarrhea, severe abdominal pain, symptoms of volume depletion, Hx of IBD
What is the likely etiology of a patient presenting with hemochromatosis (excess iron) and diarrhea?
What are the three most common causes of bacterial diarrhea in the U.S.?
Salmonella, Campylobacter, Shigella
What should be the primary differential diagnosis of frankly bloody diarrhea?
enterohemorrhagic E. coli (EHEC) - test for Shiga toxin => can progress to hemolytic uremic syndrome (HUS), an important cause of acute renal failure - indicated by low platelet count
What is the treatment for patients with clinical indications of dysentery?
avoid antimotility agents - treat with Pepto Bismol => more commonly associated with infection in the large intestine
What are the signs and symptoms of volume depletion?
dry mucus membranes, diminished skin turgor, decreased BP, altered sensorium - screen for hypokalemia and renal dysfunction